FOTO

PLANILLA DE PRE-INSCRIPCIÓN Academia Latinoamericana de Percusión

FECHA: _________________ NOMBRES: ______________________________________________ APELLIDOS:____________________________________ FECHA DE NACIMIENTO: ____________________ LUGAR DE NACIMIENTO: ____________________________ C.I:______________________________ EDAD: _______________

SEXO: F

M

E-mail: _________________________________TLF. FIJO: _____________________TLF. CELULAR: _________________ DIRECCIÓN DE HABITACIÓN favor indicar (ciudad y estado) ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ DATOS DEL REPRESENTANTE (si es menor de edad)

NOMBRES: __________________________________ APELLIDOS: ________________________________________________ TLF. FIJO: _____________________________________TLF. CELULAR: ___________________________________________

DATOS ACADÉMICOS NÚCLEO O MÓDULO:_______________________TELÉFONOS:_________________________________________ CIUDAD: ________________________________________ ESTADO: ___________________________________ AÑOS ESTUDIANDO PERCUSIÓN: ________________________ NOMBRE PROFESOR ACTUAL NÚCLEO O MÓDULO

TELÉFONO

ESTUDIOS ESCOLARES Y/O UNIVERSITARIOS GRADO (que cursa):__________________________ INSTITUCIÓN:_________________________ SEMESTRE(que cursa):__________________________ AÑO (que cursa):______________________________ GRADUADO:

SI

NO

CARRERA: ___________________________________

REPERTORIO LIBRE A AUDICIONAR REDOBLANTE:

________________________________________________________________________________________________ ________________________________________________________________________________________________ TECLADOS (MARIMBA, VIBRAFONO O XILOFONO): ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ TIMPANI: ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________

OBSERVACIONES: ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ CALIFICACIÓN :

JURADO: NOMBRES:

_____________________________________

NOTA: favor llenar la planilla en letra clara y legible es decir, letra imprenta.

PLANILLA DE PRE-INSCRIPCION ALP. PDF.pdf

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